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Career Story: Nurse And Medical Case Manager For An Insurance Company

Nurse And Medical Case Manager For An Insurance Company

Job Title: Medical Case Manager/ Licensed Practical Nurse

Type of Company: I work for an insurance company. We provide services in workers compensation, auto and property.

Education: AA, Liberal Arts, Bristol Community College (Fall River, MA) •• AA, Fine Arts, Bristol Community College •• BA, Fine Arts, Southeastern Massachusetts University (now UMass-Dartmouth, Dartmouth, MA) •• diploma, Nursing/LPN, Bristol Plymouth Vocational Technical School

Previous Experience: I worked mostly as an office nurse in Neurology. However I also worked in Pediatrics, Internal Medicine, Rheumatology and Endocrinology.

Job Tasks: I am a medical case manager in the workers' compensation division of an insurance company. My job is essentially deskbound; I do not have any direct, face-to-face contact with my patients.

When an employee is injured, depending on the injury itself or the disability period, a nurse may be assigned to his case. My job is to evaluate the medical information he receives to ensure proper care and assist the adjusters with anticipated treatment plans. I make sure my patients are getting the treatment they deserve. I also review the way the injury happened to assure that it is consistent with the injury. Ultimately I work towards having my patients released to return to work, sometimes in a modified duty capacity and then full-duty.

A typical day would be to evaluate my desktop, determine what tasks take priority and work on them. This includes following up on the patients' doctor's appointments, obtaining and evaluating medical notes and diagnostic testing, facilitating appointments etc. I often speak with medical providers to determine how my patients are progressing and whether (and how soon) they can return to work. I usually get a new claim a couple of days a week and close a few too every week. My case load at any given time is anywhere from 45-55 claims. I work closely with the claims' case managers (known as "adjusters"), the employers, medical providers and the patients. I have some dedicated accounts (insured employers) and sometimes I go off-site to meet them and look at the facility or I may meet with them in my office and go over their open claims.

Unfortunately some patients prefer to stay disabled or think they will get a big pay-out, so I sometimes have to speak with attorneys. They say we spend 80 percent of our time on 20 percent of the claims and this probably true. There are many good people out there who get injured, recuperate and go back to work. But there are always a few who need extra attention.

My employer provides me with continuing education, so sometimes I take a class during work hours. My position is very stressful. There is a lot of work to do in a short period of time.

Best and Worst Parts of the Job: The best part of my job is knowing I have helped an injured worker with his medical treatment. For instance I once had a patient who was having troubles after his surgery and was in a lot of pain and I was concerned something was wrong. Accordingly, I worked with the doctor's office to get him seen sooner and it turned out his cast had been put on incorrectly. I also like the challenge of this job. There are many different types of injuries and I learn something new every day. I am also learning about the insurance industry.

The worst part of my job is the stress. It took me two years to really learn the job and I still sometimes feel like a novice. No one does your work for you when you are out, so you have to manage your claims carefully. Also, when we take classes or have meetings, the eight hours worth of work is still there even if you spent three hours in class. My job is also very numbers-driven, meaning that the corporation looks at my claims from a financial perspective, looking at my average open/closure of claims, the amount of my claims that return to work full-duty, the amount of days of disability. Because of this there is a lot of micro-management.

Job Tips: Nursing school is very competitive, so be prepared to have excellent grades to get into the school of your choice. Recognize that nursing is a field that you will always be learning. Keep in mind too that nursing is not just working in a hospital, it is truly an open door. You can work for insurance companies the way I do, in an office setting, in a school system etc. You can travel and you can choose to work somewhere that allows you a flexible schedule.

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